RevBrasAnestesiol.2016;66(3):329---332
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
Publicação Oficial da Sociedade Brasileira de Anestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Pulse
contour
analysis
calibrated
by
Trans-pulmonar
thermodilution
(Picco
Plus
®
)
for
the
perioperative
management
of
a
caesarean
section
in
a
patient
with
severe
cardiomyopathy
夽
Nicolas
Brogly,
Renato
Schiraldi,
Laura
Puertas,
Genaro
Maggi
∗,
Eduardo
Alonso
Yanci,
Ever
Hugo
Martinez
Maldonado,
Emilia
Guasch
Arévalo,
Fernando
Gilsanz
Rodríguez
SociedadEspa˜nolaAnestesiologia,ReanimacionyTerapeuticadelDolor,Madrid,Spain
Received28June2013;accepted9September2013 Availableonline29October2013
KEYWORDS
Caesareansection; Cardiacmonitoring; Myocardiopathy
Abstract
Background: Thedeliveryofcardiacpatientsisachallengefortheanaesthesiologist,towhom thewelfareofboththemotherandthefoetusisamainissue.Incaseofcaesareansection, advancedmonitoringallowstooptimizehaemodynamicconditionandtoimprovemorbidityand mortality.
Objective: TodescribetheuseofpulsecontouranalysiscalibratedbyTrans-pulmonar thermod-ilution(PiccoPlus®)fortheperioperativemanagementofacaesareansectioninapatientwith
severecardiomyopathy.
Casereport: Wedescribethecaseofa28-year-oldwomanwithacongenitalheartdiseasewho wassubmittedtoacaesareansectionundergeneralanaesthesiaformaternalpathologyand foetalbreechpresentation.Intra-andpost-operativemanagementwasoptimizedbyadvanced haemodynamicmonitorizationobtainedbypulsecontourwaveanalysisandthermodilution cal-ibration(Picco Plus® monitor). Theinformationaboutpreload,myocardialcontractility and
postchargewasusefulinguidingthefluidtherapyandtheuseofvasoactivedrugs.
Conclusion: Thiscasereportillustratestheimportanceofadvancedhaemodynamicmonitoring withanacceptablyinvasivedeviceinobstetricpatientswithhighcardiacrisk.Theincreasing experienceinadvancedhaemodynamicmanagementwillprobablypermittodecreasemorbidity andmortalityofobstetricpatientsinthefuture.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
夽 ThisstudywasconductedatLaPazUniversityHospitalinMadrid,Spain.
∗Correspondingauthor.
E-mail:[email protected](G.Maggi).
0104-0014/$–seefrontmatter©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.
330 N.Broglyetal.
PALAVRAS-CHAVE
Cesárea; Monitorizac¸ão Cardíaca; Cardiomiopatias
Análisedocontornodopulsocalibradoportermodiluic¸ãotranspulmonar(PiccoPlus®) paraomanejoperioperatóriodecesarianaempacientecommiocardiopatiagrave
Resumo
Justificativa:O partoem pacientescardíacas éum desafiopara o anestesiologista, para o qualobem-estartantodamãequantodofetoéaquestãoprincipal.Emcasodecesariana,o monitoramentoavanc¸adopermitemelhoraracondic¸ãohemodinâmicaediminuiramorbidade emortalidade.
Objetivo:Descreverousodaanálisedocontornodopulsocalibradoportermodiluic¸ão transpul-monar(PiccoPlus®)paraomanejoperioperatóriodecesarianaempacientecommiocardiopatia
grave.
Relatodecaso:Descrevemosocasodeumapacientede28 anosdeidadecomumadoenc¸a cardíacacongênita,submetidaaumacesarianasobanestesiageraldevidoaafecc¸ãomaterna e apresentac¸ão fetal pélvica. O manejo nos períodos intraoperatório e pós-operatório foi otimizadopormonitorac¸ãohemodinâmicaavanc¸adaobtidapelaanálisedocontornodaonda depulsoecalibrac¸ãoportermodiluic¸ão(monitorPiccoPlus®).Asinformac¸õessobrepré-carga,
pós-cargaecontratilidademiocárdicaforamúteisparaorientarareposic¸ãohídricaeousode medicamentosvasoativos.
Conclusão:Esterelatodecasoilustraaimportânciadamonitorac¸ãohemodinâmicaavanc¸ada comdispositivoaceitavelmenteinvasivoempacientesobstétricascomaltoriscocardíaco.O aumentodoconhecimentonomanejohemodinâmicoavanc¸adoprovavelmentepossibilitaráa reduc¸ãodamorbidadeemortalidadedepacientesobstétricasnofuturo.
©2013SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Inthelasttwentyyears,thenumberofpatientswith con-genitalheartdisease whosurvived untiltheprocreational age has been increasing significantly.1 These patients,
when pregnant, present a high risk of cardiovascular
complications,anddeliverybycaesareansection(CS)is
rec-ommendedforthemoreseverecases.2Moreover,preventive
anticoagulationiscommoninpatientscarryingmechanical
valves,whichincreasestheriskofpostpartumhaemorrhage
andvariationsofintravascularvolumeduringdelivery.3
The use of minimally invasive haemodynamic monitors
hasproven itsusefulness in the anaesthetic management
of cardiac patients undergoing CS4---7 and cardiac output
(CO) measurement with analysis of arterial pulse wave
contour,calibratedornot,hasbeensuccessfullyemployed
inpreeclampticpatientsundergoingCS.8
We describe the case of a patient with a severe left
ventriculardysfunction,whowassubmittedtoCSandwho
benefittedduringtheperioperativeperiodfromaminimally
invasivemonitoring,usingarterialpulsecontourwave
anal-ysiscalibratedwithtranspulmonarythermodilution.
Case
report
A 28-year-old patient was followed-up for her first
preg-nancy in our tertiary hospital. She had been operated
of an atrial septum defect (ostium primum type) in the
childhood.In theearly post-operativeperiodshehad
suf-fered a mitral endocarditis that had required a valve
replacement,withfavourableoutcome.Beforepregnancy,
the patient had no clinical signs of heart failure, except
dyspnoeatypeIIaccordingtoNYHAclassification.Her
treat-ment consisted of oral anticoagulation (acenocoumarol
---Sintrom®), replaced with low molecular weight heparin
betweenthesixthandtwelfthweekofgestation.The
elec-trocardiogram showed no significant alterations and the
chestradiographrevealedanincreasedcardiothoracicratio.
Thetransthoracicechocardiogramrevealedsevereleft
ven-tricular systolic dysfunction (LVEF=24%) with no diastolic
impactandatricuspidregurgitationwithaRA-RVgradient
of40mmHgwithoutimpactonrightventricularfunction.
At 34 weeks of pregnancy, she presented uterine
con-tractions, so an emergency CS was indicated due to
maternalpathologyandbreechpresentation.Oral
anticoag-ulationwasreversedbyanintravenousdoseofprothrombin
complex (Octaplex®) 40mL (1000IU) administered before
entering the operatingroom. After having inserted
inter-nal jugular vein and femoral arterial catheters, a Picco®
monitor wasconnectedandcalibrated withthree
consec-utive bolus of cold saline. General anaesthesia (GA) was
inducedwithacontinuousinfusionofremifentanil(Ultiva®)
at0.15mcg/kg/min,etomidate(Hypnomidato®)0.3mg/kg
andsuccinylcholine(Anectine®)1mg/kg,inrapidsequence.
GAwasmaintainedwithSevoflurane(Sevoflurane®)1%.
Afterinduction of GA,the patient presented
hypoten-sionandsinusrhythmaround70bpm.AsshowninTable1,
the volumetric parametersobtained from transpulmonary
thermodilution (GEDI and ITBI) were slightly below the
acceptable limit. COwaslower thandesirable, especially
duetoasignificantdecreaseinsystolicvolumeindex(SVI),
notcompensatedbytachycardia,whichcouldbeexplained
by theaction of remifentanil.Similarly, the cardiac
func-tionindex(CFI)appeared decreased.Guidedbyavalueof
Trans-pulmonarthermodilutionperioperativemanagementcaesareansectionseverecardiomyopathy 331
Table1 SummaryofperioperativehaemodynamicvaluesofPicco®.
Pre-anaestheticsvalues Post-inductionvalues Post-deliveryvalues 6hpost-operativevalues
BR(bpm) 70 74 77 68
BP(S/D-M)(mmHg) 102/48---66 96/42---57 112/53---73 105/55---72
CVP(mmHg) 14 12 15 14
CI(L/min/m2) 2.8 2.7 4.0 3.4
SVV(%) 18 23 19 16
SVI(mL/kg) 40 36 52 50
GEDI(mL/kg) 900 907 1143 733
ITBI(mL/kg) 1080 1134 1273 916
ELWI(mL/kg) 9 8 9 9
CFI(1/min) 3.1 2.9 3.5 4.6
dPmax 900 940 3270 1460
SVRI(dynscm−5m2) 1329 1272 1566 1438
initiatea rapidinfusion of250mLof hydroxyethylalmidon (Voluven®),confidentthatthepatient’sventricularfunction
wasmaintained,andthatthefluidloadwouldnotincrease theextravascularlungwaterindex(ELWI).Indeed,theresult wasasignificantincreaseinSVI(wellover 10---15%),which normalizedarterialpressure.TheELWIandtheCFIvalues, obtained with a new thermodilution, confirmed the good response to the loading volume and the acceptable effi-ciencyoftheventriclefunction.
The patient was delivered in 7min, with no signifi-cantbloodloss(200mL),andnosignificanthaemodynamic change. Prophylaxisof uterine atonywasprovidedwith a slow infusion of 10IU of oxytocin (Syntocinon®),
adminis-teredduring30min.Thetotalamountoffluidinfusedalong theCSwas750mL(500mLofcrystalloidand250mLof col-loid)andthesurgerylasted55min.
GAwasreversedandthepatienthadhertrachea extu-batedinthe operatingroom.Shewasthen transferredto theintensivecareunitwithnohaemodynamicsupport.Her goodclinicalconditionwasconfirmedbyarterialbloodgas analysis(Table2).
The anticoagulant therapy withunfractionatedheparin
attherapeuticdose(targetACTbetween60and90s;
con-trolvalueof32s)wasstarted4haftertheendofsurgery,
onceconfirmedthatthepatientdidnotpresent excessive
bloodlossandthatthepost-operativeblood testswerein
range.
After 48h, the patient had maintained a stable
haemodynamic state with noneed for further fluidloads
or vasoactive support(Table 1). The jugularvein and the
femoralarterialcatheterswereremovedonthethird
post-operative day. An echocardiogram was performed on the
Table2 Post-operativedataofarterialbloodgas.
Value Referencevalue
pH 7.30 7.35---7.45
pCO2 32.5 35---45mmHg
pO2 113 83---108mmHg
HCO3 16 22---26Meq/L
EB −9 ±3
Lactate 0.9 0.5---2.2mmol/L
fourthdayandshowedneitherworseningofleftventricular systolicfunction(comparedwithpreoperative values)nor theformationofintracavitarythrombus.Oralanticoagulant wasreinitiated the same day, and the patientwas trans-ferredtothewardonthefifthday.Onpost-operativeday10 shewasdischargedfromthehospital,withnopost-operative complication.
Discussion
Careful peripartum management of patients presenting
cardiac impairment can reduce both morbidity and
mor-tality.Alowmyocardialcontractilereserve,aggravatedby physiological changesof pregnancy, can precipitateacute heart failure during delivery. In the most severe cases, inwhichexpulsiveeffortsmightcompromisethepatient’s
haemodynamic state, CSis recommended.9 When vaginal
delivery is possible, a proper management of pain
dur-inglabour avoidsexcessivestimulationofthesympathetic
autonomicnervoussystem,andepiduralanalgesiaisa
rec-ommendableoptiontoprovideefficientlabouranalgesia.3
Similarly, in case of CS, neuraxial anaesthesia is a very
valuableoption: itpermitstoavoidatrachealintubation,
withtherisksofunpredictabledifficultairwayand
sympa-thetichyperreflexiaduringlaryngoscopia.10 Inourcase,CS
wasperformed underemergency conditions in an
antico-agulatedpatientwithoutpredictorsofdifficultintubation:
thesewerethereasonsforchoosingGA.
Thehypervolemiaassociatedwithpregnancyreachesits
maximuminthelastweeksofgestation,withanadiratthe
timeof delivery.11 Innon-pregnantpatientswithleft
ven-triculardysfunction,littlevariationsofpre-and afterload
oftheleftventricleareoftenpoorlytolerated,sotherisk
ofheartfailureismajorattheendofpregnancyandduring
delivery.
Haemodynamic stability is essential to preserve the
maternal---foetal oxygen transport. Therefore, conditions
suchashypotensionneed carefultreatmenttoavoidfluid
overload (which can precipitate cardiogenic pulmonary
oedema) and unnecessary administration of inotropes
or vasoconstrictors, which can be harmful for the
foetal---placental circulation. When facing to hypotension
332 N.Broglyetal.
vasodilationand evenpumpfailure. Lowarterialpressure
coupledto normal or increased CO should be treated by
carefulinfusion ofvasoconstrictors,beingthesame
treat-ment dangerous in hypovolemic patients, thus it strongly
decreases placental perfusion, which lacks of
autoregula-tion.Ontheotherhand,evenahypovolemicpatientcould
badlyrespondtoa fluidchallenge, ifthe leftventricleis
operatingontheflatpartoftheFrank---Starlingcurve.Inour
case,thislastscenariocouldbereasonablysuspected,thus
acompletehaemodynamicmonitoring,includingvolumetric
parameters,wascertainlyindicated.
Protocolsbasedongoaldirectedtherapy (GDT)showed
efficiencytoimprovecriticalpatientprognosis.12Inourcase
weuseda typicalstrategy ofGDT, assuringprimarily that
intravascular volume was optimized. The left ventricle’s
abilitytohandlewithanincreaseinpreloadwasindicated
bytheSVV,adynamicparameterwithgoodsensibilityand
specificityindetectingfluidresponders.13SVVcanbeusedin
rhythmic,paralyzedandmechanicallyventilatedpatients,
which wasourscenario. Moreover, we couldemploy ELWI
to eventually detect cardiac impairment. Estimation of
lung water is obtained by transpulmonary thermodilution
and,when stable,assurethat administeredfluids arenot
increasingcardiaccongestion,provokingconsequently
pul-monary oedema. Identifying a patient who responds to
fluidadministrationpermitstoavoidtheadministrationof
vasoactive drugs (such as dobutamine or noradrenaline),
whichhavebeendescribedtoalterplacentalperfusionwhen
notindicated.14
Advanced haemodynamic monitoring is a must-have in
obstetricanaesthesiawhenfacingpatientspresentingwith
pathologies like preeclampsia or myocardiopathy, among
others.Pulmonaryarterialcatheterizationrepresentedthe
gold standard until few years ago but its use has been
reconsideredduetohighratesofcomplications;moreover,
pulmonaryarterialwedgepressurehasbeenshowntopoorly
predictfluidresponsivity.15 Recently,lessinvasive
monitor-ingtechnologieshavebeendeveloped.Arterialpulsewave
analysis allows reliable values of CO. Power analysis of
arterial wave, calibrated with lithium dilution, has been
successfully employed in preeclamptic patients8 and this
technique only requires peripheral cannulae (venous and
arterial). Thus, only transpulmonary thermodilution
pro-vides an estimation of ELWI and we considered that this
parameterwasessentialinapatientwithleftventricle
dys-function.Non-invasivetechnologies(volumeclampmethod,
transthoracicbioreactance,suprasternalDoppler)represent
a futurehope toguide haemodynamic treatment in risky
patients.16,17
In conclusion, the present case illustrates the
impor-tanceofadvancedhaemodynamicmonitoringcoupledtoan
acceptable levelof invasivity in an obstetricpatient with
high cardiac risk. The increasing experience in advanced
haemodynamicmanagementwillprobablypermittofurther
decrease morbidity and mortality of obstetric patients in
thefuture.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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